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APPROVED BY: DATE: California Department of Public Health AB 1020 Compliance Form Health and Safety Code Section 116064.2 OFFICE USE ONLY NOTE: Use one form for each pump or multiple pumps under the same suctisln fitting. THIS FORM IS INVALID IF ALL SECTIONS ARE NOT COMPLETED. This form is to be used to verify compliance with modifications pursuant to the new suction hazard prevention law. Under Section 116064.2 of the Health and Safety Code, effective January 1, 2010, the owner of a public swimming pool shall file this form within 30 days following completion of suction hazard prevention modifications. Contact your local Environmental Health Department and Building Department for any necessary plan approval and permits prior to construction or remodel. Site Information ,Tl�'pDPQ rr__L� Cd(if more than 1 pool/spa 0 GFacility Name: ndfcado FacilityAddress: 1g0A city: " St.. zip: U?#v Owner Name: Owner's Phone Number. "l-Va -r3luk Owners Address City St, Zip Pump Information ❑Recirculation Purt�p 0 ❑ Jet 1 soostar Pump Make/Model Drn'hAri ,�i+iftl�i tib �t�(L� H,P��t Make/DAodel H.P ❑Other Pump: 1 ❑ Feature Pump Make/Model H.P Make/Model H.P Manufacturer of approved suction fitting; GPM rating: Floor 'YDO. We Manufacturer of approved suction fitting: mar wauallzwr lift (J /I Model Number. r Sid- t ristali date q K -1f 10 Installed on Floor ❑ Wall Model Number. Install date GPM rating: Floor Wall Installed on O Floor ❑ Wall Main drain/Jet suction pipe size is inches. Check One: ❑ Dual main drain(s) (Minimum 3 ft between covers, hydraulically balanced and symmetrically plumbed) ffQ Single drain - Unblookable (size and shape that a human body cannot sufficiently block to create a suction entrapment) l� Single drain - Not unblockable (one of the following secondary devices required: SVR$ / Suction limiting vent / gravity drainage / auto pump shut -of/ other approved device by an rcem®nt g-e!ncy Type of secondary device installed: Manufacturer of approved device: Model/Part Number. SVRS bears the following performance standard markings: ❑ ATSM F2387 VASME/ANSI standard A 112.19.17 Skimmer Eoualiggr Iinefs) Manufacturer of approved suction fitting: �� Model Number: Install date GPM rating: GPM rating; Installed on ❑ Floor ❑ Wall Skimmer equalizer lines) pipe size were found to be inches Number of Skimmers: ❑ Single equalizer line ❑ Skimmers are separately valved before pump and can be Isolated, ❑ Dual Skimmer equalizer line(s) 0 Skimmers are connected with single line to pump. THE ABOVE HAS BEEN FIELD VERIFIED To COMPLY MANUF CTURE 'S INSTALLATION REqUIREMgNj$ BY THE.INSTALLER I declare that I hold on active California State Contractor license # 7 SS I b I with classification C_or California State Professional Engineer license # with qualified experience working on public swimming pools and that the information provided above is true to the best of my knowledge. I'm aware that improper certification of the above information shall be subject to potential disciplinary, action at the discretion of the licensing auftrity in accordance with California Health & Safety Code Section 116064.2. Contractor/Engineer Company dress: �; City: J�f1C Contractor/Engineer Phone Number. For a oomi-Ate text of R"W1 nwo 9,£;a6ed W name law, visit: B£T0b9b608T:01 �.r Company Name: State:A2 Zip Code: r b 0 Cell phone Number. Date 00TTL9S9T6 0VTTL9S9T6:W0ud 1£:80 0T02-82-8dd